Evaluating nurses' implementation of an infant-feeding counseling protocol for HIV-infected mothers: The Ban Study in Lilongwe, Malawi.

A process evaluation of nurses' implementation of an infant-feeding counseling protocol was conducted for the Breastfeeding, Antiretroviral and Nutrition (BAN) Study, a prevention of mother-to-child transmission of HIV clinical trial in Lilongwe, Malawi. Six trained nurses counseled HIV-infected mothers to exclusively breastfeed for 24 weeks postpartum and to stop breastfeeding within an additional four weeks. Implementation data were collected via direct observations of 123 infant feeding counseling sessions (30 antenatal and 93 postnatal) and interviews with each nurse. Analysis included calculating a percent adherence to checklists and conducting a content analysis for the observation and interview data. Nurses were implementing the protocol at an average adherence level of 90% or above. Although not detailed in the protocol, nurses appropriately counseled mothers on their actual or intended formula milk usage after weaning. Results indicate that nurses implemented the protocol as designed. Results will help to interpret the BAN Study's outcomes.

Involving communities in the design of clinical trial protocols: the BAN Study in Lilongwe, Malawi.

OBJECTIVE: To learn the attitudes and concerns of the local community on participating in research, infant feeding practices, and maternal nutrition in order to inform the design of a clinical trial in Lilongwe, Malawi on the safety and efficacy of antiretroviral and nutrition interventions to reduce postnatal transmission of HIV. DESIGN: Formative research methods were used, including semi-structured interviews, focus group discussions, home observations, and taste trials. Data were collected, analyzed, and incorporated into the protocol within 3 months. RESULTS: Participants were supportive of the clinical trial, although their overall understanding of research was limited. Mothers agreed that infants' blood could be drawn by venipuncture, yet concern was raised about the amount of blood proposed to be collected from both infants and mothers. Data demonstrated that rapid breastfeeding cessation would be difficult and malnutrition could be a risk if infants were weaned early. Mothers selected a maternal supplement suitable for use in the clinical trial. CONCLUSIONS: The protocol was rapidly modified to achieve cultural acceptability while maintaining study objectives. Without the formative research, several significant areas would have been undetected and may have jeopardized the implementation of the trial. Additional research was carried out to develop a meaningful informed consent process, the amount of blood collected was reduced to acceptable levels, and the protocol was modified to reduce the risk of malnutrition. Researchers who conduct clinical trials are encouraged to incorporate formative research into their protocol design to ensure participant understanding of the research, to safeguard participants, and to increase feasibility and acceptance of the clinical research in the community.

Differences between international recommendations on breastfeeding in the presence of HIV and the attitudes and counselling messages of health workers in Lilongwe, Malawi.

BACKGROUND: To prevent postnatal transmission of HIV in settings where safe alternatives to breastfeeding are unavailable, the World Health Organization (WHO) recommends exclusive breastfeeding followed by early, rapid cessation of breastfeeding. Only limited data are available on the attitudes of health workers toward this recommendation and the impact of these attitudes on infant feeding counselling messages given to mothers. METHODS: As part of the Breastfeeding, Antiretroviral, and Nutrition (BAN) clinical trial, we carried out an in-depth qualitative study of the attitudes, beliefs, and counselling messages of 19 health workers in Lilongwe, Malawi. RESULTS: Although none of the workers had received formal training, several reported having counseled HIV-positive mothers about infant feeding. Health workers with counselling experience believed that HIV-infected mothers should breastfeed exclusively, rather than infant formula feed, citing poverty as the primary reason. Because of high levels of malnutrition, all the workers had concerns about early cessation of breastfeeding. CONCLUSION: Important differences were observed between the WHO recommendations and the attitudes and practices of the health workers. Understanding these differences is important for designing effective interventions.

Multivitamin use in relation to self-reported body mass index and weight loss attempts.

CONTEXT: There are scant data on patterns of multivitamin use among US adults in terms of body mass index (BMI) or whether one is trying to lose weight. OBJECTIVE: To examine multivitamin use and beliefs about multivitamin use among adults according to BMI and to determine whether use by body weight differs if one is trying to lose weight. DESIGN: Cross-sectional multivariate analysis of the HealthStyles consumer survey. The final analytic sample consisted of 2239 women and 1532 men. MAIN OUTCOME MEASURES: Prevalence and odds of multivitamin use by demographic and behavioral characteristics including BMI, use by weight loss intent, and among users, reasons for use. RESULTS: 63.7% of women and 52.9% of men reported multivitamin use (taking 1 or more multivitamin per week). Obese women were less likely than normal-weight women to use multivitamins; no differences according to BMI category were detected for men. Among women who were not trying to lose weight, obese women were less likely than normal-weight women to use multivitamins (odds ratio = 0.63, CI 0.41-0.98). Assessment of reasons for use found that compared among women not trying to lose weight, those trying to lose weight were more likely to report multivitamin use because It is important for my health. CONCLUSIONS: This descriptive analysis adds to the limited literature on multivitamin use according to both body weight and attempting to lose weight. Multivitamin use was common and decreased with increasing BMI. This may be because fewer obese people consider vitamins "important for their health".

Associations between body mass index and the prevalence of low micronutrient levels among US adults.

BACKGROUND: Low micronutrient levels observed with increasing adiposity may result from inadequate nutrient intake and/or alterations in nutrient metabolism. OBJECTIVE: To examine the association between body mass index (BMI) and micronutrient levels among a nationally representative sample of US adults aged > or = 19 years. DESIGN: Using nationally representative cross-sectional data from the National Health and Nutrition Examination Survey III (NHANES III), we examined odds ratios of low micronutrient levels using logistic regression adjusting for covariates. MEASUREMENTS: Nutritional biomarker levels (as indicated by serum levels of total carotenoids, alpha-carotene, beta-carotene, beta-cryptoxanthin, lutein/zeaxanthin, lycopene, vitamin E, vitamin C, selenium, vitamin A, vitamin D, folate, vitamin B12, and red blood cell folate) among men and nonpregnant women, by BMI category. RESULTS: Overweight and obese adults had higher odds of low levels for a number of nutrients compared with normal-weight adults. Odds of being low in multiple micronutrients was most common among overweight and obese premenopausal women. CONCLUSION: These findings underscore the need for further assessment of specific micronutrient inadequacies among persons who are overweight or obese. Specifically, research is needed to determine whether these inadequacies are due to insufficient dietary intake, altered metabolic processes, or both.

Perceptions of the role of maternal nutrition in HIV-positive breast-feeding women in Malawi.

A neglected issue in the literature on maternal nutrition and HIV is how HIV-positive women perceive their own bodies, health, and well-being, particularly in light of their infection, and whether these perceptions influence their infant feeding practices and their perceived ability to breast-feed exclusively through 6 mo. We conducted formative research to better understand breast-feeding practices and perceptions, and to inform the Breastfeeding, Antiretroviral, and Nutrition (BAN) Study, a clinical trial to evaluate antiretroviral and nutrition interventions to reduce mother-to-child transmission of HIV during breast-feeding in Lilongwe, Malawi. Twenty-two HIV-positive women living in semi-rural areas on the periphery of Lilongwe participated in in-depth interviews. In an adaptation of the body-silhouette methodology, nine culturally appropriate body silhouettes, representing a continuum of very thin to very large shapes, were used to elicit women's views on their present, previous-year, and preferred body shapes, and on the shape they perceived as healthy. The narrative scenario method was also used to explore women's views on 2 fictional women infected with HIV and their ability to exclusively breast-feed. Women perceived larger body shapes as healthy, because fatness is considered a sign of good health and absence of disease, and many recognized the role of nutrition in achieving a preferred or healthy body shape. Several women believed their nutritional status (body size) was declining because of their illness. Women were concerned that breast-feeding may increase the progression of HIV, suggesting that international guidelines to promote appropriate infant feeding practices for infants whose mothers are infected with HIV should focus on the mother's health and well-being, as well as the infant's.

What epidemiologic studies tell us about the relationship between fruit and vegetable consumption and body weight.

Clinical evidence shows that combining advice to increase fruit and vegetable consumption with caloric restriction is an effective strategy for weight management. The purpose of this review is to evaluate epidemiologic evidence to determine whether it supports an association between fruit and/or vegetable consumption and body weight. Few studies have been designed to specifically address this issue, and those that are available vary in methodology and offer inconsistent results. We make recommendations on how to strengthen future studies so that the influence of fruit and vegetable consumption on body weight in free-living individuals is better understood.

What can intervention studies tell us about the relationship between fruit and vegetable consumption and weight management?

Given the recent surge in obesity, effective dietary strategies for weight management are required. Because fruits and vegetables are high in water and fiber, incorporating them in the diet can reduce energy density, promote satiety, and decrease energy intake. Although few interventions have specifically addressed fruit and vegetable consumption, evidence suggests that coupling advice to increase intake of these foods with advice to decrease energy intake is a particularly effective strategy for weight management. This approach may facilitate weight loss because it emphasizes positive messages rather than negative, restrictive messages.